Advanced Cardiac Life Support Provider Course

Held in conjunction with the

Texas Society of the
American College of Osteopathic Family Physicians
50th Annual Convention
July 25-26, 2007
 Introduction

In 2005, the American Heart Association published new guidelines for Basic Life
Support and Advanced Cardiac Life support as well as Pediatric Advanced Life Support.
This course will endeavor to update experienced provider with the new guidelines and
new providers with the latest information available.

Some of this material has already been released to the general public through news media
sources. New provider and instructor manuals have been released containing the latest
information. “Currents”, the journal of the AHA ECC, has published those guidelines to lead
instructors and faculty as can be made available at:

http://www.americanheart.org/downloadable/heart/1132621842912Winter2005.pdf
.
New course materials can now be found at:

http://www.txacofp.org/ACLS
Advanced Cardiac Life Support Provider Course Objectives

4. Describe the Advanced Cardiac Life Support (ACLS) Chain of Survival approach to emergency
cardiovascular care. (I)
5. Describe elements of emergency cardiovascular care. (I-II)
6. Describe the systematic approach to ACLS. (I-III)
7. Identify and describe human, moral, ethical, and legal issues of Basic Life Support (BLS) and
ACLS. (IV)
8. Describe and demonstrate airway assessment. (V)
9. Describe and demonstrate basic airway equipment and management techniques. (V)
10. Describe and demonstrate techniques for oxygen delivery, advanced airway equipment, and
ventilation and management techniques. (V)
11. Describe intravenous therapy. (VII)
12. Analyze and interpret electrocardiogram (ECG) rhythms and asystole. (VIII)
13. Analyze and interpret the ECG. (VIII)
14. Define the processes of myocardial ischemia, myocardial injury, and myocardial infarction, and
describe how they are identified on the ECG. (VIII-IX)
15. Describe and demonstrate electrical therapy, including defibrillation, automated external
defibrillation (AED), synchronized cardioversion, and transcutaneous pacing. (X)
16. Describe pharmacological therapy used in management of emergency cardiovascular care. (XI)
17. Describe the acute coronary syndromes in terms of pathophysiology, risk factors, clinical
presentation, and assessment of the ischemic chest pain/acute myocardial infarction (AMI)
patient. (XII)
18. Describe management of specific AMI presentations including mechanical, pharmacologic, and
electrical interventions. (XIII)
19. Describe algorithms, emergency cardiovascular care, and protocols for the patient in cardiac
arrest, including ventricular fibrillation/pulseless ventricular tachycardia, pulseless electrical
activity, and asystole. (XIII)
20. Describe algorithms, emergency cardiovascular care, and protocols for bradycardia and
tachycardias. (XII)
21. Describe post-resuscitation patient management. (XIII)
22. Describe the etiology, risk factors, clinical presentation, assessment, management, differential
diagnosis, and special considerations of a patient with acute stroke and transient ischemic attack
(TIA). (XIII)
23. Describe special resuscitation situations, including traumatic cardiac arrests, the pregnant cardiac
arrest patient, lightning strikes, hypothermia-induced cardiac arrest, submersion emergencies, and
toxicological cardiac emergencies. (XIII)
24. Describe management for each core case in ACLS. (XIV)
25. Score a minimum of 80% on a written exam. (XV)
2005 ACLS Bridge Algorithms
 Case #1
Respiratory Emergencies
“All It Takes Is A little Air........”

An 68 year old male is found slumped over in his pickup truck in a convenience store parking lot
in a rural area. Bystanders know him as only Mr. Smith. His neighbor says he has been sick for 3
days, but to his knowledge, has no medical problems. On arrival, EMS personnel note that the
man is dusky in color. He is breathing in gasping respirations at 30-35/minute. He is unable to
speak (presumably due to his tachypnea), but follows commands with his eyes. A non-rebreather
mask is applied with oxygen flow set at 15 L./minute. No pulse oximetry readings are obtained
by EMS. The transport time was approximately 7 minutes.

On arrival, vital signs showed a blood pressure of 80/40 mmHg., pulse of 135/min. in normal
sinus rhythm by monitor, respirations were gasping at 35-38/minute, temperature was 99.2
degrees F. Normal sinus rhythm was confirmed by 12 lead EKG with no ST segment
abnormalities noted. Breath sounds demonstrated extensive rales and rhonchi. Chest radiographs
shows extensive bilateral infiltrates, especially in the lower lobes. In light of a satisfactory EKG,
blood gas measurements were obtained. The pH= 7.2, pO2=143, pCO2= 248, O2 sat= 85%. A
diagnosis of respiratory failure was made. Nasotracheal intubation was performed and the patient
attached to a mechanical ventilator. Ventilations were set at 15 SIMV, PEEP =5, FiO2=100%,
Tidal volume= 750
ml.. Oxygen saturation improved dramatically. The patient began to make purposeful
movements. He was transferred to the Intensive Care Unit via stretcher with mechanical
ventilation.

ACLS protocols used:

1) Respiratory Failure/Arrest with a pulse
2) Stable tachycardia

Comments:

There are a number of issues this case brings to bear. First, the lack of history made the treatment
empirical. Certainly, a cardiac etiology must be considered and was investigated with physical
examination, x-ray, EKG and laboratory studies. The poor
blood gas values precluded waiting for cardiac enzymes to be returned from the laboratory (they
were all within normal limits). Prompt attention to the airway and mechanical assistance was
indicated due to worsening respiratory fatigue of the patient.
A presumptive diagnosis of bilateral pneumonia was made. (sputum cultures later showed
Hemophilus influenzae type IIIb).
Moral of the Case:
AIRWAY, BREATHING, CIRCULATION

"Hey this ACLS stuff really works....." EMT delivering a patient to the emergency department after a successful
defibrillation at home
 Case #2
Ventricular Fibrillation Treated with CPR and Automated
External Defibrillator Algorithm

Establish unconsciousness.
↓
Check pulse
↓
Activate the Emergency Response Team (eq. Call 911)
↓
Give one rescue breath over one second. Reposition if unable to give a breath. Breath
should provide visible chest rise.
↓
Use automated external defibrillator as soon as possible.
↓
Provide just compressions over the center of the chest between the nipples. Compress at
a rate of 100 compressions per minute. Allow chest recoil. Limit interruptions and chest
compressions.
↓
Provide compressions and a 30: 2 compression to ventilation ratio.
↓
Apply automated external defibrillator. Do not attack interrupt CPR to apply patches.
Providers should consider two minutes or five cycles of CPR before defibrillation in an
unwitnessed arrest.
↓
Shock once, then resume CPR.
 Case #3

Ventricular Fibrillation/Pulseless Ventricular Tachycardia

Time is Myocardium!

A 48 year old male summoned EMS with a chief complaint of chest pain located
anteriorly and radiates to both arms. The pain worsens when he leans forward. He states that the
pain has been present for 3 hours , but has been intermittent for 7 days previous. He states that he
was treated for an upper respiratory tract infection 14 days ago. He describes the pain as a 10 on
a scale of 1 to 10. EMS personnel start IV access and give supplemental oxygen by nasal
cannula. Nitroglycerin tablets sublingually are given enroute, but fail to improve symptoms. He
is then given morphine sulfate intravenously which greatly improves symptoms. Transport time
was 10 minutes. The monitor strip shows normal sinus rhythm in Lead II.

On arrival, an EKG is performed showing ST segment elevation in V1,V2,V3,V4 with

reciprocity in Leads II, III and AVF. There was no diaphoreis or dypsnea. After receiving IV
Demerol, the patient pain is graded as a 5 out of 10. He denies a history of hypertension or
iabetes. He is a recovering alcoholic and "speed" abuser. Cardiac enzymes were within
tolerances. No acute patterns were seen in isoenzymes. A working diagnosis of acute anterior
myocardial infarction versus pericarditis was made and arrangements were made to place the
patient on a telemetry floor. Prior to making the transfer, the patient abruptly became
unresponsive and developed coarse ventricular fibrillation. Rapid cardiac defibrillation at 360
joules resulted in a conversion to normal sinus rhythm which rapidly changed to paroxysmal
supraventricular tachycardia. The patient was refractory to adenosine and then required
synchronized cardioversion at 50 joules to convert back to normal sinus rhythm. The patient now
awake and alert was transported by air to a tertiary care center for further evaluation.

ACLS protocols used:

1) Ventricular fibrillation
2) PSVT, narrow complex

Comments: While the patient's history left many diagnostic possibilities, the ST segment
elevation suggested acute myocardial infarction. Thrombolysis might well have been indicated
had the diagnosis been arrived at earlier. But the likelihood of reperfusion ventricular arrhythmia
must be anticipated. No specific risk factors were identified.Lastly, the necessity of air transport
for this patient is questionable since there are risks inherit with air transport. It is unclear which
elements of care were not immediately available at presenting medical center.

Remember: Time is myocardium!

 Case #3

Ventricular Fibrillation/Pulseless Ventricular Tachycardia

Algorithm

Establish unconsciousness.
↓
Check pulse
↓
Activate the Emergency Response Team (eq. Call 911)
↓
Give one rescue breath over one second. Reposition if unable to give a breath. Breath
should provide visible chest rise.
↓
Provide just compressions over the center of the chest between the nipples. Compress at
a rate of 100 compressions per minute. Allow chest recoil. Limit interruptions and chest
compressions.
↓
Provide compressions and a 30: 2 compression to ventilation ratio.
↓
Advanced airway placement may be delayed several minutes to avoid interruption of
chest compressions. The laryngeal mask airway or commie to provide effective
ventilation. Avoid hyperventilation. If an advanced airway tube is inserted, chest
compression should be delivered at 100 compressions per minute and ventilations of
eight to 10 breaths per minute (one breath for every six to eight seconds).
↓
Deliver one defibrillation shock

Recommended energy:
• 360 J monophasic.
• 150 J to 200 J for biphasic truncated exponential waveform.
• 120 J for biphasic rectal linear waveform.
• Deliver 200 J if not sure of biphasic waveform subsequent
doses may be the sameor higher.
↓
CPR
↓
Attempt to establish either intravenous or interosseous access.
 ↓
Shock
↓
CPR
While performing CPR consideration of the administration of vasopressors
and antiarrhythmics should be considered
↓
Vasopressors

• Vasopressin 40 units IV or
• Epinephrine 1 mg. IV or
• Epinephrine 2 mg. per endotracheal tube
↓
Antiarrhythmics

• Amiodarone 300 mg. IV

• consider Lidocaine (1 mg./kg.), only if Amiodarone is not
available
 Case #4
Pulseless Electrical Activity
(rhythm on monitor, without detectable pulse)

If the victim of any age has a sudden witnessed collapse, the collapse is likely to
be cardiac in origin, and the healthcare provider should activate the emergency
response system, get an AED when available, and returned to thevictim to provide
CPR and use the automated external defibrillator when appropriate.
↓
If the victim of any age has a likely hypoxic (eg. asphyxsial) arrest, such as a
drowning, the lone healthcare provider should give five cycles (about two
minutes) of CPR before leaving the victim to activate the emergency response
team and retrieve an AED.
↓
Insertion of an advanced airway may not be a high priority. If an advanced airway
is inserted, rescuer should no longer deliver cycles of CPR. Chest compression
should be delivered continuously at 100 per minute and rescue breaths delivered
at a rate of 8 - 10 breaths per minute (one breath every 6 to 8 seconds).
↓
Treat the underlying rhythm:
• Ventricular Fibrillation
• Pulseless Ventricular Tachycardia
• Asystole
↓
Consider underlying causes:
• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
• Hyper/Hypokalemia
• Hypothermia
• Tablets (Intentional/Accidental Drug Overdose)
• Tamponade, Cardiac
• Tension Pneumothorax
• Thrombosis, Coronary (Acute Coronary Syndrome)
• Thrombosis, Pulmonary
↓
Epinephrine 1 mg. IV or 2 mg. per endotracheal tube may be administered IV
push and repeated every three to five minutes as a vasopressor.
↓
Atropine 0.5 mg. IV (if the rate is slow less than 50 per minute) to seize may
be repeated every three to five minutes as needed to a total dose of 0.04 mg
per kilogram.
 Case #5
Asystole

The algorithm for treatment of pulseless arrest was reorganized to include:

• Ventricular fibrillation
• Pulseless ventricular tachycardia
• Asystole
• Pulseless Electrical Activity.
↓
Insertion of an advanced airway may not be a high priority. If an advanced airway is inserted, the
rescuers should no longer deliver cycles of CPR. Chest compression should be delivered
continuously.
↓
Providers must organize care to minimize interruption in chest compressions for rhythm check,
shocked delivery, advanced airway insertion, or faster access.
↓
Increased information about the use of the laryngeal mask airway and endotracheal esophageal-
tracheal Combi-tubes is encouraged. Use of endotracheal intubation is limited to providers with
adequate training and opportunities to practice and perform intubations.
↓
Treatment of asystole/pulseless electrical activity includes:
• Epinephrine 1 mg administered every three to five minutes.
• One dose of Vasopressin may replace either the first or second dose of epinephrine.
 Case #6
Acute Coronary Syndrome
 Case #7

Bradycardia
 Case #8
Unstable Tachycardia

The treatment of tachycardia is summarized in a single algorithm. Immediate synchronized

cardioversion is still recommended for the unstable patient. If the patient is stable, a 12 lead ECG
you or a rhythm strip enables classification of the tachycardia as narrow complex or wide
complex these two classifications can be further subdivided into those with regular or irregular
rhythms.
↓
There is an emphasis on determining stable versus unstable rhythms and preparing for immediate
cardioversion. If the patient demonstrates rate related cardiovascular compromise with signs and
symptoms such as:

• altered mental status

• ongoing chest pain
• hypotension
• diaphoresis
• or other forms of shock

Then the patient should receive immediate synchronized cardioversion. Serious signs and
symptoms are uncommon if the ventricular rate is less than 150 beats per minute in a patient with
a healthy heart. Patients with impaired cardiac function or significant comorbid conditions may
become symptomatic at lower heart rates. If the patient is unstable with narrow complex reentry
supraventricular tachycardia, you may administer adenosine while preparations are made for
synchronized cardioversion. But, do not delay cardioversion to administer the drug or establish
IV access.
↓
The recommended initial dose for cardioversion of atrial fibrillation is 100 - 200 J with a
monophasic waveform. A dose of 100 J to 120 J is reasonable with the biphasic waveform.
Escalate the second and subsequent shock doses as needed. Cardioversion of atrial flutter and
other supraventricular tachycardias generally require less energy. An initial energy of 50 J to 100
J monophasic damped sign waveform is often sufficient. If the initial 50 J shock fails, increase
the dose in stepwise fashion. More data is needed before detailed comparative dosing
recommendations for cardioversion by biphasic waveforms can be made.
↓
Current research confirms that it is reasonable to use selected energies of 150 J to 200 J with the
biphasic truncated exponential waveform or 120 J with the rectal linear biphasic waveform for
the initial shock. For second and subsequent biphasic shocks, use the same or higher energy. The
provider should use the biphasic device - specific dose, the default dose is 200 J. If a monophasic
defibrillator is used, use 360 J for all unsynchronized shocks.
 Case #9
Stable Tachycardias

If the patient is stable, a 12 lead ECG (or rhythm strip) enables the classification of the
tachycardia as a narrow-complex or wide complex. The two classifications can be further divided
into those with regular or irregular rhythms. Initial rate control with diltiazem, beta-blockers, or
magnesium for patients with atrial fibrillation with rapid ventricular response is recommended.
Amiodarone, ibutilide, propafenone, flecainide, digoxin, clonidine, or magnesium can be
considered for rhythm control in patients with atrial fibrillation of less than 48 hours duration.
↓
Adenosine is safe and effective in pregnancy. Adenosine however, does have several important
drug interactions. Larger doses may be required for patients with significant blood levels of
theophylline, caffeine, or theobromine.
↓
Synchronized cardioversion is appropriate for treatment of monomorphic (regular) wide complex
tachycardia, particularly if the patient is symptomatic. If the rhythm is identified as a likely
ventricular tachycardia in an unstable patient, IV antiarrhythmic drugs may be effective. If
antiarrhythmics are administered, the American Heart Association recommends amiodarone.
↓
See Algorithm
 Case #10
Acute Thrombotic Stroke